MOAA DBQ Worksheet MOAA DBQ Worksheet Users Guide If you complete a Disability Benefits Questionnaire (DBQ) the processing time for your VA claim will decrease. Instead of waiting for the VA to schedule you for an exam, your private physician fills out a form explaining your diagnosis and the severity of your condition. DBQs start on the next page. The VA will not pay for or reimburse you for any expenses associated with getting a DBQ form filled out by a private physician. Generally p TRICARE physicians will not fill a DBQ or make a medical statement in support y y pp of a VA claim. y ask your physician if they are willing to fill out the DBQ form before you schedule your appoinment. You will also need to submit an Authorization and Consent to Release form (VA 21-4142) to the VA for your DBQ. The form must be completed, printed and signed or the VA will not accept it. Information about how the VA evaluates disabilities and what the VA considers a disability for rating purposes can be found in Title 38 of the United States Code and Title 38 of the Code of federal Regulations. There is a DBQ available for most conditions ratable by the VA, but not all. You will need to have a VA exam for certain conditions. Disabilities or Conditions for which there is no DBQ available for use by United States Code Code of Federal Regulations Private Doctors. Title 38 CFR § 4.129 Initial Diagnosis of PTSD Title 38 USC § 1155 Hearing Loss or Tinnitus Residuals of Traumatic Brain Injury (TBI) Title 38 USC § 1155 Title 38 CFR § 4.87 Title 38 USC § 1155 Title 38 CFR § 3.159 & 3.26 & 3.28 Residuals of Cold Injury Title 38 USC § 1155 Title 38 CFR § 3.159 & 3.26 & 3.28 Prisoner of War Exam Protocol Title 38 USC § 1155 Title 38 CFR § 3.17 Gulf War Medical Exam General Exam for Compensation Title 38 USC § 1155 Title 38 CFR § 3.17 Title 38 USC § 1155 Title 38 CFR § 3.159 & 3.26 & 3.28 General Exam for Pension Title 38 USC § 1155 Title 38 CFR § 3.159 & 3.26 & 3.28 Presumptive or Exposure Related Regulations United States Code Code of Federal Regulations Herbicide Exposure Title 38 USC § 1112 Title 38 USC § 1116 Title 38 CFR § 3.307 & 3.309 Gulf War (Undiagnosed Illness) Title 38 USC § 1117 Title 38 CFR § 3.317 Ionizing Radiation Title 38 USC § 501 Title 38 CFR § 3.311 & 3.715 Mustard Gas Title 38 USC § 501 Title 38 CFR § 3.316 Title 38 USC § 1112 Title 38 CFR § 3.307 & 3.309 Presumption or Exposure Tropical Wartime Presumptions Title 38 CFR § 3.816 Other Relevant Regulations Rule or Regulation United States Code Code of Federal Regulations Amputations N/A Title 38 CFR § 4.68 Paired Organs or Extremities (Bilateral Factor) Title 38 USC § 1160 Title 38 CFR § 3.383 & 4.26 Spina Bifida Title 38 USC § 1805 & 1811-1834 Title 38 CFR § 3.814 & 3.815 Multiple Non-Compensable Disablities N/A Title 38 CFR § 3.324 Presumption of soundness Title 38 USC § 1111 Title 38 CFR § 3.303 - 3.305 Claims related to Tobacco Use Title 38 USC § 1103 Title 38 CFR § 3.300 Duty to Assist Title 38 USC § 5103A Title 38 CFR § 3.159 Accrued Benefits Title 38 USC § 5121 Title 38 CFR § 3.152 & 3.1000 Substitution Title 38 USC § 5121A N/A Prohibition Against Duplication of Benefits (Concurrent Receipt) Title 38 USC § 5304 & 5305 Title 38 CFR § 3.654 & 3.750 & 3.751 Annual Adjustment of Certain Benefit Rates (COLA) Title 38 USC § 5312 N/A Housebound (Survivors) Title 38 USC § 1122 & 1502 Title 38 CFR § 3.351 Aid and Attendance (Survivors) Title 38 USC § 1311 and 1315 Title 38 CFR § 3.351 & 3.352 Fugitive Felons Title 38 USC § 5313B Title 38 CFR § 3.665 & 3.666 Permanent and Total Ratings and Unemployability Title 38 USC § 501 & 1155 & 1502 Special Monthly Compensation (Aid and Attendance for Veterans) Title 38 USC § 1114 Title 38 CFR § 3.350 & 3.552 Analogous Ratings N/A Title 38 CFR § 4.20 Functional Loss N/A Title 38 CFR § 4.40 Painful Motion N/A Title 38 CFR § 4.59 Page 1 of 8 38 CFR § 3.340-3.342 & 4.16-4.18 MOAA DBQ Worksheet Cardiovascular Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Ischemic Heart Disease Ischemic Heart Disease VA 21-0960A-1 The Cardiovascular System 38 CFR 4.100-4.104 7000-7123 Evaluation of varicose veins, arterial diseases, producing swelling, claudication of legs, or pain on walking, skin/nail changes Artery and Vein Conditions (Vascular Diseases including varicose veins) VA 21-0960A-2 The Cardiovascular System 38 CFR 4.100-4.104 7000-7123 Evaluation of high blood pressure (BP): how to determine significance of BP readings or BP reading abnormalities. Hypertension VA 21-0960A-3 The Cardiovascular System 38 CFR 4.100-4.104 7000-7123 Conditions including: heart attack (MI), irregular rhythm, heart murmurs and heart surgery. Heart conditions (Including IHD, Non-IHD, Arrhythmias Valvular Disease and Cardiac Surgery) VA 21-0960A-4 The Cardiovascular System 38 CFR 4.100-4.104 7000-7123 Dental and Oral Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of all dental and oral conditions, except TMJ Conditions. Dental and Oral Conditions VA 21-0960D-1 Dental and Oral Conditions 38 CFR 4.150 9900-9916 Dental and Oral Conditions 38 CFR 4.150 9900-9916 Evaluation of conditions affecting the Temporomandibular Joint (TMJ) Conditions TMJ joint with pain in the jaw when biting VA 21-0960M-15 and clicks and sounds in the jaw. Dermatological Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation for infectious and noninfectious diseases of the skin: how to evaluate rashes, spots, athlete's foot, sweating, and acne skin lesions. Skin Diseases VA 21-0960F-2 The Skin 38 CFR 4.118 7800-7833 Evaluation of palpable or disfiguring scars, producing distortion or asymmetry. Scars and Disfigurement VA 21-0960F-1 The Skin 38 CFR 4.118 7800-7833 Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of various conditions of the ear including: infections, dizziness, vertigo, acoustic tumors and other conditions with ringing in the ears (tinnitus). Ear Condition (including: Vestibular and Infectious Conditions) VA 21-0960N-1 Impairment of Auditory Acuity 38 CFR 4.85-4.87 6200-6260 Other Sense Organs 38 CFR 4.87a 6275-6276 Ear, Nose, Throat Evaluation of Anosmia (inability to detect any odor), Hyposmia (reduced ability to Loss of Sense of Smell and/or detect odors), Ageusia (complete lack of Taste taste), Hypogeusia (decrease in sense of VA 21-0960N-3 taste) and other conditions affecting the sense of smell and taste. Evaluation of conditions affecting, the sinuses, nose, throat, larynx, and pharynx, including, but not limited to deviated nasal septum and organic aphonia, vocal chord problems. Sinusitis, Rhinitis, and other The Respiratory System Conditions of the Nose, Throat, Diseases of the Nose and Throat Larynx, and Pharynx 38 CR 4.96-4.97 VA 21-0960N-4 Page 2 of 8 6502-6524 MOAA DBQ Worksheet Endocrinological Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of DM Type I or II, with alteration of blood sugar regulation, abnormal Glucose Tolerance Test (GTT), requiring medication or hospitalization or complications. Diabetes Mellitus VA 21-0960E-1 The Endocrine System 38 CFR 4.119 7900-7919 Evaluation of conditions affecting the hormone glands, including, but not limited to Cushing's syndrome, Acromegaly, and Addison's Disease. Endocrine Diseases (other than Thyroid and Parathyroid, or Diabetes Mellitus) VA 21-0960E-2 The Endocrine System 38 CFR 4.119 7900-7919 Evaluation of conditions affecting the functions regulated by the thyroid and parathyroid glands, including, but not limited to growth and metabolism. Thyroid and Parathyroid Conditions VA 21-0960E-3 The Endocrine System 38 CFR 4.119 7900-7919 Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes The Digestive System 38 CFR 4.110-4.114 7200-7354 The Digestive System 38 CFR 4.110-4.114 7200-7354 Evaluation of Irritable Bowel Syndrome Intestinal Conditions (other than (IBS) (chronic recurrent diarrhea or surgical or infectious) including constipation). Ulcerative colitis (chronic Irritable Bowel Syndrome, inflammatory bowel condition leading to Crohn's Disease, Ulcerative erosions and bleeding) and other Colitis, and Diverticulitis conditions with Bloody stools, fistulas, VA 21-0960G-3 and/or abscess. The Digestive System 38 CFR 4.110-4.114 7200-7354 Evaluation of hepatitis (which refers to a variety of inflammatory and infectious conditions) and Cirrhosis (chronic liver disease resulting from liver injury leading to degeneration of the liver) and other conditions characterized by jaundice, ascitis, fluid retention. Hepatitis, Cirrhosis and Other Liver Conditions VA 21-0960G-5 The Digestive System 38 CFR 4.110-4.114 7200-7354 Evaluation of peritoneal adhesions, which are scars of the visceral lining of the abdominal structures that produces episodes of partial or complete bowel obstruction. Peritoneal Adhesions VA 21-0960G-6 The Digestive System 38 CFR 4.110-4.114 7200-7354 Evaluation of stomach and duodenum Stomach and Duodenum conditions such as peptic ulcer disease, Conditions (not including GERD recurrent pain relieved by antacids, or Esophageal Disorders) bloody stools, nausea or vomiting, VA 21-0960G-7 indigestion. The Digestive System 38 CFR 4.110-4.114 7200-7354 Evaluation of Amebiasis, dysentery, and Infectious Intestinal Disorders, various types of intestinal parasites with including Bacterial and Parasitic recurrent diarrhea, alteration in stool Infections consistency or foul smell. VA 21-0960G-8 The Digestive System 38 CFR 4.110-4.114 7200-7354 Evaluation of removal of portions of the intestine and reconstruction and diversion of the intestinal tract: bowel diversion that requires use of external bags to collect stool. The Digestive System 38 CFR 4.110-4.114 7200-7354 Gastrointestinal Evaluation of conditions affecting the Esophageal Conditions esophagus such as stricture, spasm, or (including GERD, Hiatal Hernia, other conditions with lump in throat or and Other Esophageal chest, pain on swallowing, or Disorders) regurgitation. VA 21-0960G-1 Evaluation of gallbladder disease, with inflammation, gallstones, pain after eating fatty food, or pancreatic conditions including pancreatitis that manifests as severe recurrent abdominal pain. Gallbladder and Pancreas Conditions VA 21-0960G-2 Intestinal Surgery (Bowel Resection, Colostomy, and Ileostomy) VA 21-0960G-4 Page 3 of 8 MOAA DBQ Worksheet Genitourinary Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of renal diseases including Nephritis, renal insufficiency, and other Kidney Conditions (Nephrology) diseases of the kidney: kidney failure, VA 21-0960J-1 abnormal kidney function tests, protein in the urine, edema, kidney stones. The Genitourinary System 38 CFR 4.115-4.115b 7101 & 7500-7542 Evaluation of diseases of the urethra, penis, testes, and scrotum, producing pain on urination, swelling, blood in urine or incontinence. Male Reproductive Organ Conditions VA 21-0960J-2 The Genitourinary System 38 CFR 4.115-4.115b 7101 & 7500-7542 Evaluation of malignant lesions of the prostate gland with frequent diurnal or nocturnal urination. Prostate Cancer VA 21-0960J-3 The Genitourinary System 38 CFR 4.115-4.115b 7101 & 7500-7542 Evaluation of conditions affecting the bladder and urethra, including, but not limited to voiding dysfunctions and infections. Urinary Tract (Bladder and Urethra) VA 21-0960J-4 The Genitourinary System 38 CFR 4.115-4.115b 7101 & 7500-7542 Gynecological Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of inflammatory neoplastic and cystic lesions of the breast: Breast mass or lumps. Breast Conditions and Disorders VA 21-0960K-1 Gynecological and Disorders of the Breast 38 CFR 4.116 7610-7627 Evaluation of diseases of the female genital tract including: uterus, vagina, cervix, ovaries, endometriosis, complications of pregnancy, and other conditions. Gynecological Conditions VA 21-0960K-2 Gynecological and Disorders of the Breast 38 CFR 4.116 7610-7627 Hematologic and Lymphatic Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Hairy Cell and Other B-Cell Leukenias Hairy Cell and Other B-Cell Leukenias VA 21-0960B-1 The Hemic and Lymphatic System 38 CFR 4.117 7700-7717 Evaluation of conditions of red and white blood cells, producing anemias, leukemias on tumors such as lymphomas. Hemotologic and Lymphatic Conditions VA 21-0960B-2 The Hemic and Lymphatic System 38 CFR 4.117 7700-7717 Infectious Diseases Conditions/Symptoms Form Name Code of Federal Regulations Infectious Diseases, Immune Disorders and Nutritional Deficiencies 38 CFR 4.88 Infectious Diseases, Immune Disorders and Nutritional Deficiencies 38 CFR 4.88 Diagnostic Codes Evaluation of conditions associated with the Human Immunodeficiency Virus (HIV) and its treatment. HIV Related Illnesses VA 21-0960I-2 Evaluation of infectious diseases not specifically-associated with either HIV or military service in a tropical area, the Persian Gulf, or Afghanistan. Infectious Diseases VA 21-0960I-3 Evaluation of infectious diseases associated with military service in tropical areas with exposure to salmonella, shigella, etc. producing symptoms such as chronic diarrhea. Persian Gulf and Afghanistan Infectious Diseases VA 21-0960I-1 Infectious Diseases, Immune Disorders and Nutritional Deficiencies 38 CFR 4.88 & 38 CFR 3.317 6300-6354 Evaluation of conditions in which the Systemic Lupus Erthematosus immune system begins attacking healthy (SLE) and Other Autoimmune body tissues, including, but not limited to, Diseases Goodpasture's syndrome and GuillainVA 21-0960I-4 Barre syndrome. Infectious Diseases, Immune Disorders and Nutritional Deficiencies 38 CFR 4.88 6300-6354 Page 4 of 8 6300-6354 6300-6354 MOAA DBQ Worksheet Infectious Diseases Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of pulmonary and extrapulmonary tuberculosis symptoms. Tuberculosis (TB) VA 21-0960I-6 Infectious Diseases, Immune Disorders and Nutritional Deficiencies 38 CFR 4.88 6300-6354 For use in evaluation of vitamin deficiencies (Beriberi, Pellagra, syndromes of dermatitis, diarrhea dementia in POW, post-GI surgery, bypass procedures, undernutrition and malabsorption.) Nutritional Deficiencies VA 21-0960I-5 Infectious Diseases, Immune Disorders and Nutritional Deficiencies 38 CFR 4.88 6300-6354 Musculoskeletal Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of extremity, limb or digit (complete or partial amputation), and complications. Evaluation of stumps. Amputations VA 21-0960M-1 The Musculoskeletal System Prosthetics & Amputations 38 CFR 4.40-4.73 5051-5173 Evaluation of ankle pain, persistent deformity (ankylosis), ankle injuries, reduction of movement, and use of assistive device. Ankle Conditions VA 21-0960M-2 The Musculoskeletal System The Ankle 38 CFR 4.40-4.73 5270-5274 Evaluation for non-degenerative arthritic conditions such as Gout and Rheumatoid Arthritis: recurrent painful and swollen joints. Non-degenerative Arthritis (including Inflammatory, Autoimmune, Crystalline, and Infectious Arthritis) and Dysbaric Osteonecrosis VA 21-0960M-3 The Musculoskeletal System Acute, Subacute, or Chronic Diseases 38 CFR 4.40-4.73 5000-5025 The Musculoskeletal System 38 CFR 4.40-4.73 5000-5329 Evaluation of injuries, deformities, loss of Elbow and Forearm Conditions elbow and forearm producing motion VA 21-0960M-4 limitation. Evaluation of flatfoot, and acquired deformity of the foot. Flatfoot (Pes Planus) VA 21-0960M-5 The Musculoskeletal System 38 CFR 4.40-4.73 5000-5329 Evaluation of reduction or loss of toe function and motion, and alteration in mobility. Foot Miscellaneous (other than Flatfoot) VA 21-0960M-6 The Musculoskeletal System 38 CFR 4.40-4.73 5000-5329 Evaluation of alteration in motion of the wrists or digits due to tendon or muscle injuries, and alteration in motion and function of the hand including ankylosis, trigger finger, loss of finger movement. Hand and Finger Conditions VA 21-0960M-7 The Musculoskeletal System 38 CFR 4.40-4.73 5000-5329 Evaluation of alteration in extension and flexion, poor postural and body support, and alteration of rotation of the hip. Hip and Thigh Conditions VA 21-0960M-8 The Musculoskeletal System 38 CFR 4.40-4.73 5000-5329 Evaluation of ankylosis of the knee, subluxation of the knee, knee instability, Knee and Lower Leg Conditions meniscus lesions, and functional VA 21-0960M-9 limitations knee cartilage problems, locked knee. The Musculoskeletal System 38 CFR 4.40-4.73 5000-5329 Evaluation of traumatic and other injuries resulting in loss or alteration of function, location, type, tears, and weakness: torn scarred muscles. The Musculoskeletal System 38 CFR 4.40-4.73 5000-5329 Muscle Injuries VA 21-0960M-10 Page 5 of 8 MOAA DBQ Worksheet Musculoskeletal Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of bone infections producing fever, local alteration of function, residuals from a bone infection with persistent drainage or bone alteration Osteomyelitis VA 21-0960M-11 The Musculoskeletal System Acute, Subacute, or Chronic Diseases 38 CFR 4.40-4.73 5000-5025 Evaluation of arm limitation of function, dislocation, alteration in joint function, incomplete movements, deformity, dislocation, nonunion, and fracture complications : frozen shoulder. Shoulder and Arm Conditions VA 21-0960M-12 The Musculoskeletal System 38 CFR 4.40-4.73 5000-5329 Evaluation of arthritis and neck deformities. Neck (Cervical Spine) Conditions VA 21-0960M-13 The Musculoskeletal System 38 CFR 4.40-4.73 5319-5323 Evaluation of unfavorable or incomplete wrist motion due to ankylosis (limitation in range), painful or other alteration in function, resulting from traumatic or other injury complications, joint replacement. Wrist Conditions VA 21-0960M-16 The Musculoskeletal System 38 CFR 4.40-4.73 5000-5329 Evaluation of chronic low back pain, arthritis and back injuries, spinal conditions or disc disease: low back pain with sciatica. Back (Thoracolumbar Spine) Conditions VA 21-0960M-14 The Musculoskeletal System 38 CFR 4.40-4.73 5235-5243 Neurological Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of progressive degenerative disease of the brain and spinal cord with progressive muscle weakness and wasting, speech, swallowing and breathing problems. Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease) VA 21-0960C-2 Neurological Conditions and Convulsive Disorders Organic Diseases of the Central Nervous System 38 CFR 4.120-4.124a 8000-8025 Evaluation of alteration of the function of the nerves (motor and sensory), related to Diabetes Mellitus: weakness, numbness, tingling of legs and arms related to diabetes. Diabetic Sensory-Motor Peripheral Neuropathy *Analogous Rating VA 21-0960C-4 Neurological Conditions and Convulsive Disorders 38 CFR 4.120-4.124a 8000-8914 Neurological Conditions and Convulsive Disorders 38 CFR 4.120-4.124a 8000-8914 Neurological Conditions and Convulsive Disorders Diseases of the Cranial Nerves 38 CFR 4.120-4.124a 8205-8412 Neurological Conditions and Convulsive Disorders Miscellaneous Diseases 38 CFR 4.120-4.124a 8100-8108 Central Nervous System and Neuromuscular Diseases Evaluation of numerous other neurologic (except TBI, ALS, Parkinson's conditions such as: meningitis, HIV, brain Disease, MS, Headaches, TMJ, abscess, Lyme Disease, encephalitis, Epilepsy, Narcolepsy, stroke, brain tumor, and spinal cord Peripheral Nerves, Sleep injury. Apnea, Cranial nerves, Fibromyalgia, and CFS) VA 21-0960C-5 Evaluation of conditions affecting the following nerves in the Cranium: V (trigeminal, VII (facial), IX (glossopharyngeal), X (vagus), XI (spinal accessory), and XII (hypoglossal). Cranial Nerve Conditions VA 21-0960C-3 Evaluation of recurrent episodes of head Headaches (including Migraine pain producing work limitation or Headaches) incapacitation: with other symptoms such VA 21-0960C-8 as nausea, vomiting, tearing etc. Page 6 of 8 MOAA DBQ Worksheet Neurological Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of fibromyalgia components, including, but not limited to sleep problems, muscle and joint pain, and altered affect. Fibromyalgia VA 21-0960C-7 The Musculoskeletal System Acute, Subacute, or Chronic Diseases 38 CFR 4.40-4.73 5000-5025 Evaluation of disorders of the myelin sheath of the central nervous systems producing recurrent alterations of neurological function: such as weakness, numbness, urine incontinence, visual symptoms. Multiple Sclerosis (MS) VA 21-0960C-9 Neurological Conditions and Convulsive Disorders Organic Diseases of the Central Nervous System 38 CFR 4.120-4.124a 8000-8025 Evaluation of symptoms that may include tremors, or trembling in hands, arms, legs, jaw, and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; and postural instability, or impaired balance and coordination. Parkinson's Disease *Analogous Rating VA 21-0960C-1 Neurological Conditions and Convulsive Disorders Organic Diseases of the Central Nervous System 38 CFR 4.120-4.124a 8000-8025 Evaluation of narcolepsy components, including, but not limited to, sleep attacks, sleepiness, paralysis, and cataplexy. Narcolepsy VA 21-0960C-6 Neurological Conditions and Convulsive Disorders 38 CFR 4.120-4.124a 8000-8914 Evaluation of alteration of the function of Peripheral Nerve Conditions Nerves associated with metabolic (not including Diabetes Sensorydisorders, exposure to toxins, infections, Motor peripheral Neuropathy) immunological disorders, or inflammation VA 21-0960C-10 and other conditions. Neurological Conditions and Convulsive Disorders 38 CFR 4.120-4.124a 8000-8914 Evaluation of seizure conditions including epilepsy. Neurological Conditions and Convulsive Disorders The Epilepsies 38 CFR 4.120-4.124a 8910-8914 Seizure Disorders VA 21-0960C-11 Ophthalmological Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of various diseases of the eye, such as inflammation, infection, glaucoma, deformities, alteration of tear ducts, cataracts, retina disease, and other conditions. Eye Conditions VA 21-0960N-2 Organs of Special Sense 38 CFR 4.75-4.79 6000-6091 Psychological Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation for anorexia, bulimia, and other eating disorders. Eating Disorders VA 21-0960P-1 Mental Disorders 38 CFR 4.125-4.130 9201-9521 Evaluation of symptoms, history, and impact related to mental disorders: depression, mood and affective disorders, psychosis, etc. Mental Disorders (other than PTSD) VA 21-0960P-2 Mental Disorders 38 CFR 4.125-4.130 9201-9521 Evaluation of beginning and extent of symptoms (acute - length of symptoms is usually less than 3 months, chronic symptoms usually last 3 months or more, with delayed onset - usually at least 6 months have passed between the traumatic experience and the beginning of symptoms). Review Evaluation of PTSD VA 21-0960P-3 Mental Disorders 38 CFR 4.125-4.130 9201-9521 Page 7 of 8 MOAA DBQ Worksheet Respiratory Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of the respiratory system except Sleep Apnea and Tuberculosis. Respiratory Conditions (other than TB and Sleep Apnea) VA 21-0960L-1 The Respiratory System 38 CR 4.96-4.97 6502-6847 Evaluation of disorder characterized by cessation of breathing during sleep and provides information necessary to determine functional impact (sleep apnea, snoring) daytime complications. Sleep Apnea VA 21-0960L-2 The Respiratory System 38 CR 4.96-4.97 6502-6847 Rheumatological Diseases Conditions/Symptoms Form Name Code of Federal Regulations Diagnostic Codes Evaluation of Chronic Fatigue Syndrome. Components including but not limited to tiredness, loss of memory or concentration and enlarged lymph nodes. Chronic Fatigue Syndrome VA 21-0960Q-1 Infectious Diseases, Immune Disorders and Nutritional Deficiencies 38 CFR 4.88 6354 General Surgical Conditions/Symptoms Form Name Evaluation of conditions involving internal Hernias (including Abdominal, organs bulging through the muscle, Inguinal, and Femoral Hernias) except hiatal hernia. VA 21-0960H-1 Evaluation of rectum and anus conditions causing alteration of sphincter control, stricture of prolapse, fistula, and other symptoms. Code of Federal Regulations Diagnostic Codes The Musculoskeletal System 38 CFR 4.73 & The Digestive System 38 CFR 4.110-4.114 5324-5329 & 7338-7340 The Digestive System 38 CFR 4.110-4.114 7330-7340 Rectum and Anus Conditions (including Hemorrhoids) VA 21-0960H-2 Additional Notes Authorization and consent to release information to the Department of Veterans Affairs (VA) VA 21-4142 Page 8 of 8
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